Moda Health Network Adequacy Waivers

Moda Health has network adequacy waivers approved by the Texas Department of Insurance for the 2025 Plan Year. Refer to the Network Adequacy Table linked below for information on Moda Health’s network adequacy waivers.

Moda Health Network Adequacy Table - 2025

Affected Counties:

• Hays
• Travis
• Williamson

Access Plan Procedures:

Access Plan Procedures apply when a network adequacy waiver has been approved by the Texas Department of Insurance.

When Moda Health does not have at least two in-network providers of the required specialties within the required time and distance standards as defined by TIC 1301.00553, Moda has developed an in-network exception process.

The in-network exception process allows member cost sharing at the in-network level. Balance billing applies if not prohibited by Federal or State law.

• Step 1: Review Provider Directory
  • Members should review Moda Health’s online provider directory to find an in-network provider. Find Care is Moda Health’s online directory of in-network providers. To search for in-network providers, members should log in to their Member Dashboard at modahealth.com/texas and click on “Search for providers”.
• Step 2: Call Customer Service
  • If members are unable to find an in-network provider of the specialty needed, members should call Moda Health’s customer service team at the number listed on the back of their member ID card.
• Step 3: Customer Service Review
  • Moda Customer Service will review to confirm no in-network providers are available.
  • Customer Service will identify at least three providers available in Moda’s travel network, First Health.
    • If a member goes to a provider available in the First Health network, benefits will be at the in-network cost sharing amount and rate and members cannot be balance billed.
  • If members request a specific out-of-network provider, Customer Service may request an in-network exception. If a specific out-of-network provider is requested by the member, the in-network exception process allows for member cost sharing at the in-network level. Balance billing applies if not prohibited by Federal or State law.